Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization A Randomized Quality Improvement Trial

Background:

Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.

Objective:

To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.

Design:

Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526)

Setting:

5 U.S. Department of Veterans Affairs (VA) medical centers.

Patients:

Primary care patients at high risk for hospitalization who had a recent acute care episode.

Intervention:

Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts.

Measurements:

Utilization and costs (including intensive management program expenses) 12 months before and after randomization.

Results:

2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (−$2164 [95% CI, −$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization.

Limitations:

Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed.

Conclusion:

High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs.

Primary Funding Source:

Veterans Health Administration Primary Care Services.

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